*Purpose: Early stage hepatocellular carcinoma (HCC) patients meeting the Milan Criteria have access to Orthotopic Liver Transplantation (OLT) as a curative treatment. However, a substantial percentage of patients diagnosed with HCC lie outside of the Milan parameters. The Metro ticket calculator designed by Dr. Mazzafero et al. shows the oncologic price to pay if OLT is attempted for patients with more significant tumor burden. However, anecdotal data shows that some patients transplanted beyond Milan criteria may still have good tumor biology that translates to reasonable outcomes. We aim to identify and characterize patients beyond Milan Criteria that were transplanted without paying the oncologic price.

*Methods: From a database of over 2000 patients we identified 645 patients that had undergone OLT for cancer. One hundred and forty-one patients were identified that had tumor burden beyond Milan. Patients were then grouped based on the presence or absence of recurrence. Patient demographics, date of surgery, operative parameters, explant pathology, date of recurrence and death were obtained. Statistical analysis was performed using Chi Square, Student’s T test, Cox-proportional Hazard, Kaplan -Meier curves as needed using SAS software.

*Results: Median age of all patients was 59years and 85% were male. Nineteen percent of patients beyond milan had a recurrence. No differences were noted in MELD or AFP scores, however patients that recurred had higher T. bili 3+/-3 vs 6+/-9; p&lt0.05. No differences were noted in number of LRTs between the 2 groups (2+/-1 vs. 2.5+/-2, p=0.16). Additionally, patients who recurred had similar lymphocyte counts but an elevated absolute neutrophil count 3+/-2 vs 4+/-3’p<0.05 and NLR 3+/-2 vs 5+/-5;p&lt0.05. Explant pathology for the 2 groups is shown below

*Conclusions: These data show that patients beyond Milan criteria can have recurrence free survival. Furthermore, while patient with recurrences do not demonstrate a greater frequency of LRTs they do have higher bilirubin levels and a more inflammatory milieu accompanied by a relative lymphopenia. Furthermore, on explant pathology recurrers were found to be more likely to have poorly differentiated tumors with high nuclear grade. Therefore, we conclude that patients beyond Milan criteria with good tumor biology can be identified preoperatively by biochemical characteristics and can be transplanted without paying the oncologic price.

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